A manual of minor surgery and bandaging : for the use of house-surgeons, dressers and junior practitioners

Front matter

I

STUDENTS’ BOOKS.

MAYNE’S MEDICAL VOCABULARY; or, an Explanation of all Terms and Phrases used in the various Departments of Medical Science and Practice. Fourth Edition. Fcap. 8vo, 10s.

Preface To The Fiest Edition

In writing the following pages, my object has primarily been to offer to those young surgeons, who are holding the responsible post of house-surgeon or dresser in the various hospitals and dispensaries, some hints on the treatment of the numerous accidents and emergencies daily coming under their care. Having myself filled the offices of dresser and house-surgeon to a metropolitan hospital, and having, moreover, been a constant attendant at two such institutions since that time, I venture to hope that the suggestions here incorporated will he found serviceable. It has been my endeavour to avoid, as far as possible, the repetition of matter which will he found at greater length hi the various handbooks of surgery, and rather to call attention to those minor points which are imparted only by oral instruction, or are simply imitated from one’s predecessors.

Although, for convenience, specially addressed to house-surgeons, I am not without hope that these suggestions may he found serviceable by any who are

Preface

IX anxious to gain a knowledge of the smaller details of surgery, which, after all, tend greatly to the success of surgical practice ; and particularly by those who may not have had the opportunity of residing for a time within the walls of an hospital.

In the chapters on ‘ Bandaging’ and ‘ Apparatus’ I have endeavoured to avoid unnecessary complexity, at the same time, however, alluding to most of the appliances in common use in the metropolitan hospitals, the greater number of which I have visited with this special object in view.

The illustrations are all new and original, being careful copies, by Mr Swain, of Bouverie Street, from photographs taken for the purpose, under my own superintendence.

I have to thank numerous friends for kind suggestions and assistance, and specially Dr Anstie, for revising the chapter on ‘ Chloroform,’ and Dr Buzzard, for his artistic assistance with regard to some of the illustrations, and for selecting the pharmacopoeial formula; at the end of the work.

CHRISTOPHER HEATH.

April 1861.

Introduction

Relation of House-Surgeon to Dressers, Visiting Surgeon, Secretary and Matron, Chaplain, Students— Nurses— In-patients — Diet — Medicine — Fresh air — Accidents — Certificates — Law — Care of own health, . . pp. 1-10

Chapter I

Haemorrhage — General treatment — Haemorrhage from accidents— Scalp wounds — Wounds of face — Cut lip — Bleeding from nose — from ear— Bitten tongue — Teeth knocked out — Cut throat — Ruptured froenum — Stabs — Wounds of arteries — Wounds of palmar arch — Wounds of veins — Haemorrhage from disease — Epistaxis — Syphon-tube — Haemorrhage from rectum — from bladder — Bloody urine — Ruptured varicose veins— Ulceration and sloughing— Haemorrhage after surgical operations — after extraction of teeth — Haemorrhagic diathesis — from the tonsils — Leech-bites — Intermediary haemorrhage — Haemorrhage after incisions — Secondary haemorrhage — Haemorrhage after lithotomy — Tube en chemise — Appliances for arresting haemorrhage— pressure — tourniquets— forceps — ligature — Method of tying — Acupressure— Torsion, pp. 11-37

Chapter II

Wounds — contused and lacerated — after-treatment of — Wound of cornea — of sclerotic — Liebreicli’s eye-bandage — over shin — of joints — Bruises and contusions — Sprains

XU

CONTENTS.

— Strains — Ruptured tendo Acliillis — Machinery accidents— Burns and scalds — Scalds of glottis — Injuries from firearms and gunpowder — Gunshot injuries — Bites and stings — Suspended animation — Marshall Hall’s and Sylvester’s methods — Concussion and compression — Diagnostic table of — Foreign bodies in eye — Lime in oye — Foreign bodies in ear or nose, larynx, trachea, oesophagus, bladder, urethra, rectum, and vagina, pp. 38-64

Chapter III

Retention of urine — from spasmodic stricture — from permanent stricture— from enlarged prostate — from paralysis of bladder — from calculus — Retention in female — Extravasation of urine — Washing out bladder — Washing catheters — Paraphimosis — Strangulated hernia — Diagnostic table of — Prolapsus ani — Rape, . pp. 65-81

Chapter IV

Immediate treatment of cases of Poisoning — Alcoholic poisoning— diagnosis from apoplexy — treatment — Opium poisoning — treatment — Oxalic acid — treatment — Hydrocyanic acid and the cyanides — Mineral acids — treatment— Caustic alkalies — treatment, . . pp. 82-86

Chapter V

Minor operations — Laryngotomy — Tracheotomy — tubes for — pilot trochar — Paracentesis — Aspiration — V enesection — Bleeding from jugular vein — from temporal artery — Incisions into inflamed parts — Abscesses — Antiseptic treatment of abscess — Whitlows— Introduction of eye-drops — Plugging the nares— Puncture of tonsil — Removal of tonsil — Spray-producer — Local anesthesia — Amputation of fingers — of toes — Use of stomach-pump — Introduction of rectum-tube and bougie — Rectal abscess —An inflamed pile— Circumcision— Tapping hydrocele — Ingrowing toe-nail — Seton — Issue — Cupping — Aplication of nitric acid — Subcutaneous injection — Vaccination and preservation of lymph, . . ■ pp. 87-121

CONTENTS.

Xlll

Chapter VI

Operating theatre — Esmarch’s bloodless method — Removal of patient— Patient’s bed — Treatment after operations— Antiseptic dressings— First dressing after operations — Slinging stumps — Bed-sores — Administration of chloroform— Nitrous oxide gas — Ether, . . pp. 122-143

Chapter VII

Dressings— dry — water — absorbent — evaporating — Antiseptic gauze — Drainage tubes — Irrigation — Ointments — Collodion— Sealing— Poultices — Strapping — to strap a limb — to strap a joint — Scott’s dressing — to strap testicle — to strap breast, pp. 144-160

Chapter VIII

Bandages — Rolling machine — spiral — figure-of-eight — for leg — for ankle — for knee — Spica of groin — both groins — for breast — both breasts — for finger — penis — for all fingers — thumb — arm — axilla — for head — Capeline— for stump — T bandage — many -tailed— Handkerchiefs — Slings —

To tie in catheter — five methods — Lithotomy-tie — Retractors, . pp. 161-189

Chapter IX

Fractures — diagnosis — Simple fractures— dislocations accompanying fractures — compound fractures — setting fractures— Nelaton’sand Bryant’s lines — Apparatus — splints — pads — splint-room — gutta percha, leather, leather-felt — poro-plastic — immovable apparatuses, starch, chalk-and-gum — plaster-of-Paris — plaster-of- Paris splints — glue bandage — paraffine bandage — silica bandage — sand-bags, pp. 190-209

Chapter X

Special fractures — of skull — of base of skull — spine — pelvis — nasal bones — lower jaw — ribs — clavicle— Ellis’s apparatus for — humerus — forearm — Colics’ — Gordon’s

XIV

CONTENTS.

splints — metacarpal bones —phalanges — thigh — application of long splint — double-inclined plane — extension by straps of plaster — extension by weight — elastic extension — patella — tibia — fibula — Pott’s fracture — foot, pp. 210-236

Chapter XI

Dislocations — clove hitch — Dislocation of jaw — clavicle — humerus — Diagnosis of injuries of shoulder — Dislocation at elbow — at wrist — Injury of arm in children — dislocation of phalanges — Levis’s apparatus for reducing — ‘ the Siamese link ’ — femur— at knee— at ankle — Treatment after excision of joints — shoulder— elbow — Heath’s splint for — Mason’s splint for — wrist — hip — hammock-swing — knee — ankle, . . pp. 237-253

Chapter XII

Case-taking — importance of — order of particulars — history of case — description of case — diagnosis and treatment — progress — pulse, respiration, temperature — result — Case-books— Table for reporting a surgical case, pp. 254-262

Chapter XIII

Post-mortem examination — of head — to remove the brain— to open the orbit — to remove temporal bones — to remove spinal cord — chest and abdomen — thorax— heart — larynx — abdomen — to remove the urethra and bladder — Average weights of organs, . pp. 263-275

Pharmacopceial Formulae of the London Hospitals, p. 276

Hospital Diet Tables, .... pp. 287, 288

Index, p. 289

LIST OF ILLUSTRATIONS.

8. 9.

20. 21. 22.

Syplion-tube for nose,

Lithotomy tube en chemise,

Reef-knot and ‘ Granny, ’

Mode of tying a ligature,

Torsion of arteries,

Liebreich’s eye-bandage,

Sylvester’s method of artificial inspiration, Ditto expiration,

Angular forceps,

Horse-hair probang, closed,

Ditto, open,

India-rubber bottle, .

Mode of securing tracheotomy tube, Durham’s tracheotomy-tube,

Pilot trochar for tube,

Venesection,

Bandage after Venesection,

Eye-drop bottle,

Guillotine for tonsil, .

The spray-producer, .

Dr Brakenridge’s instrument,

Amputation of finger,

Ditto, by oval method,

Dressing for stump, .

Sling for stumps,

Strapping leg, .

,, knee and ankle,

,, testicle,

,, breast,

Bandage rolling machine,

„ ' spiral, .

„ figure-of-eight,

„ for leg,

,, for knee,

35 37 41 55 55 60 62 63 73

93 93

97 101

105 105

156 158

159 162 164

166 166

XVI

LIST OP ILLUSTRATIONS.

PAGE

40. Bandage, spica, for groin, 167

41. ,, for both groins, 168

42. ,, for breast, 169

43. ,, for both breasts, 170

44. ,, for finger, 171

45. ., for all the fingers, : 172

48. ,, for axilla, 175

54. ,, sling for hand, 182

55. ,, sling for arm, 183

56. ,, method of tying in catheter, . . . 185

57. ,, Thompson’s method of ditto, . . . 186

60. Diagnostic lines about hip-joint, .... 199

61. Leather splint for hip-disease, 199

62. Bandage for fractured jaw, ..... 213

63. ,, for fractured clavicle, 215

64. Ellis’ apparatus for ditto, ... ... 216

65. Splint for humerus, 217

66. Three splints for ditto, 219

67. Splints for forearm, 220

68. Splint for Colies’ fracture, 221

69. 70. Gordon’s splint for ditto, 222

72. Double thigh splints for children, .... 226

73. Extension of fractured thigh by weight, . . . 227

74. Pulley for weight extension, 228

75. Buckston Brownie’s thigh extension, .... 229

77. Extension of fractured thigh by elastic band, . . 231

78. Splints for leg, 234

79. Clove-hitch, 238

81. Levis’ apparatus for dislocated fingers, . . . 245

82. Mode of reducing dislocation of foot, .... 247

83. Heath’s splint for excised elbow, . . . .249

84. Mason’s splint for ditto, ...... 250

85. Extension of hip by weight, 251

FOE

HOTJSE-SUKGEONS,

INTRODUCTION.

The office of house-surgeon to a public hospital is one of the most responsible posts a young surgeon can occupy, and, at the same time, its value in giving him both experience and confidence can he scarcely too highly estimated. Before, however, entering upon the more purely surgical duties of the house-surgeon, it may be well to say a few words on his relation to the other officials of the establishment, to the patients, and to the public.

Being resident, the House-Surgeon has the entire charge of all the surgical in-patients during the absence of the principal medical officers, and under his care also come all the casualties which may occur between the regular visits. This rule is modified in some hospitals by the fact that the Dressers are held responsible for the welfare of both in-patients and casualties, the house-surgeon occupying merely the post of a supervisor, who can be appealed to in the event of any special emergency; but, for brevity’s sake, in the following pages the term House-Surgeon is employed to signify the responsible and acting officer.

It is obvious that the above arrangement must modify materially the relative positions of house-surgeon and dresser ; in the one case the dresser being entirely subor-

MINOR SURGERY AND BANDAGING.

dinate, while, in. the other, he acts in a great degree on his own responsibility. It is not within the scope of this work, however, to enter into these minutice, which are sufficiently regulated by the traditions prevalent in each institution.

The relation of the house-surgeon to the Visiting- Surgeon varies also in different institutions, and with different individuals. Some visiting-surgeons wish to do everything themselves, and are very wroth if a house-surgeon has opened an abscess or tightened a bandage; while others allow their subordinates considerable liberty, provided the patients suffer no harm. Here, again, tradition and observation during student-life will enable the house-surgeon to keep clear of all collision with his superior officers ; and he is certainly hound to respect the reasonable prejudicesof eachsurgeon withregard to the details of his practice, and not to attempt to bring the practices of two or three individual surgeons to one uniform level, by which all possibility of comparison would he lost.

It is most important, both for his own comfort and for the welfare of the patients, that the house-surgeon should keep on good terms with the non-medical portion of the establishment, ordinarily represented by a Secretary and a Matron. These latter officers being permanent, and often of long standing, have frequently considerable power with the committee and governors at large, and have unfortunately also occasionally very strong views with respect to the manner in which the house-surgeon’s duties are to he conducted ; and it is sometimes difficult to venture in the least degree from the beaten track, even in a good direction, without offending their prejudices. A gentlemanly hearing and the exercise of proper tact will, however, often enable a house-surgeon to overcome difficulties at first sight insuperable, and it will generally he found, that when a house-surgeon has got into ‘ hot-water ’ with the officials, it lias been owing to some false step or want of courtesy on his own part. Should the house-surgeon find, however, that he is interfered witli in the proper discharge of his duties by

INTRODUCTION.

any one, he is bound to state the facts to the superior medical officers, that the matter may be at once invests gated and set right; for if any encroachment be permitted, the next occupant of the office may be still more harassed in the proper fulfilment of his charge.

It is to be hoped that the house-surgeon will never interfere with the duties of the Chaplain, seeing that the spiritual care of the sick is not within the housesurgeon’s province; the only difficulty at all likely to arise in this quarter is the tendency of some chaplains to prolong their visits to the wards to the inconvenience of the dressers and others, but this can be easily remedied by a proper representation of the fact. The house-surgeon is bound to respect the privacy of a ward when prayers are being read, except in the case of accident or sudden emergency, when everything must yield to the necessities of the case.

Since most hospitals have medical schools attached to them, the house-surgeon may be of the greatest possible service to the Students, by encouraging their visits to the wards, and by taking the trouble to give a little clinical instruction in making his rounds. This will prepare himself also for more formal clinical teaching, should he ever occupy the position of surgeon to an hospital; and since to teach is to learn, he can have no better way of improving himself in the practice of his profession. It would be well also if the house-surgeon would bear in mind the necessity for clinical observation, and take care that, when possible, the students should be summoned to witness any operation or remarkable accident which may occur at other than the regular hour of the surgeon’s visit. With this view, also, the house-surgeon might possibly be self-denying enough not to reduce all dislocations, &c.,instanter, when an hour’s delay would not be of the smallest consequence to the patient, and would allow the students to see an accident such as they may be soon called upon to attend in private, and to witness its appropriate treatment at the hands of the visiting-surgeon. The house-surgeon must of course guard his patients

MINOR SURGERY AND BANDAGING.

against the meddling of inexperienced students, and have due regard also to the comfort and privacy of the wards, especially those occupied by female patients.

As the well-doing of the patients depends in no inconsiderable degree upon the good understanding between the house-surgeon and the 1ST urses, its maintenance should always be aimed at. Nurses often have views of their own with regard to the treatment of cases, which, if kept within proper hounds, may he of considerable sendee, for the inexperienced house-surgeon may not unfrequently gain useful hints from an intelligent woman who has been for years in the wards of an hospital; he must be careful, therefore, not to disgust his subordinates, in the first blush of office, by any sweeping revolutions or startling novelties. By an invariably courteous, and at the same time firm, behaviour, the house-surgeon will soon gain the confidence of nurses, who would, perhaps, prove insubordinate to a vacillating and rude officer, of even greater professional abilities. Two difficulties which are to be guarded against with respect to the nurses are, the tendency they have (in order to save trouble) to do all the dressing themselves, instead of leaving them for the proper dressers, and the exhibition of favouritism to certain patients. To obviate the former, the dresser must be careful to attend in proper time, so that the general business of the ward is not delayed; and the latter must be judiciously checked, or if necessary, may be prevented by transferring the patient to another ward. It can hardly be necessary to deprecate in the strongest terms any undue familiarity between the house-surgeon and the nurses or female patients, which no one who has any proper sense of honour would allow himself to indulge in for a moment.

The In-patients are in most hospitals admitted under the surgeon of the week or day on which they may happen to apply, but invariably any case sent specially to any individual surgeon is admitted under his particular care, and the house-surgeon should be careful to attend to this, as the infringement of the rule generally creates

INTRODUCTION.

some ill-feeling. The division of the beds among the several surgeons will vary in different institutions, and there is generally an understood ‘ give-and-take ’ arrangement, which obviates all overcrowding.

Unless evidently perfectly clean, or unless the severity of the inj ury or disease prevent it, all in-patients should have a warm bath before being put to bed, and even when the bath is not available, as much dirt as can should be removed by the nurse with soap and water. Except in the case of some very sudden emergency, a patient should never be put into the bed occupied by another without the linen having been changed, and, if at all soiled, the blankets also. (In all hospitals the rule is, that when a death has occurred the whole of the bedding should be changed.) The allowance of clean linen to each bed varies very considerably in different institutions, and a change will be required much more frequently in some cases than in others ; but where the allowance is small, a neat appearance can be given to the beds by always placing a clean sheet first atop of the patient, and after a day or two shifting it to underneath him, and replacing it by another clean one, and so on. The house-surgeon should not consider the details of the bed of a patient as infra dig., since his progress may materially depend upon his comfort in it. It will often make all the difference between a good and a sleepless night to a weary patient, if all crumbs, &c., are carefully swept out of the bed, and the sheets are thoroughly smoothed and tucked in on each side.

With regard to Diet, the house-surgeon has more liberty in some hospitals than in others, but should always endeavour to avoid extravagance, and particularly the continuance of large quantities of stimulants or extras after the necessity for their administration is past. A table of the diet-rolls of some of the metropolitan hospitals will be found at tbe end of this book. Some little skill will be necessary in order to suit the capricious appetite of a failing patient, and there is ordinarily no difficulty in obtaining special niceties for

MINOR SURGERY AND BANDAGING.

such, cases, on making a representation of the facts to the matron or steward.

In the matter of Medicine, the house-surgeon should, as a rule, not commence a course of treatment without the sanction of the visiting-surgeon, and should he he obliged to make any alteration in the surgeon’s absence, must be careful to inform him at his next visit, otherwise neither surgeon nor patient will have fair play. Even in cases where no medicine is required, it satisfies the patient’s mind to have something on the medicinecard, and hence ‘ R Ilaust. Sennas co. fgiss. pro re nata,’ is a useful prescription.

Fresh air is, perhaps more necessary than medicine for surgical patients, and the house-surgeon should see that the ventilation of the wards is properly carried out, and, if possible that the windows are opened at certain periods of the day. Attention must, however, be paid to the state of the atmosphere and direction of the wind, for if with a bitter east wind, windows facing that way are opened, the patients will often suffer severely from catarrh or erysipelas. Window-sashes which direct the current of air upwards, can often be opened when the ordinary draughty window would do much harm to the patients. The use of disinfecting lotions, &c., will do away with much of the offensive odour of unhealthy wounds, and, if necessary, cloths may be hung round a patient’s bed soaked in some disinfecting fluid, which may also be sprinkled on the floor. A pill-box perforated with pin-holes, and filled with metallic iodine, is found in the cancer wards of the Middlesex Hospital to be a most effectual deodorant when affixed to each patient’s bed ; and at Guy’s Hospital Dr Steele has contrived a revolving jack-towel in miniature, one end of which passes through a trough containing a solution of carbolic acid, which is thus constantly evaporated in the neighbourhood of offensive or contagious cases. The water-closets and urinals in connection with the wards should be occasionally inspected, to see that they are perfectly sweet, and when the bed-pan is employed it

INTRODUCTION.

should contain a little disinfecting fluid or powder, and be emptied immediately after being used. Those patients who are able to do so should be encouraged to go out into the fresh air, and all who are able should be up during the day-time, and, if not strong enough to be thoroughly dressed, may lie outside the bed with advantage.

The prevailing custom of constantly scrubbing the floors of the wards with soap and water has a decided tendency to maintain a moist, unhealthy atmosphere, particularly in the winter months. The practice of polishing and dry-rubbing the floor would be a great improvement, and is said ( e.g . at Birmingham) to have a direct tendency to reduce the mortality from erysipelas, &c.

The house-surgeon should make an invariable rule of seeing all cases of Accident as soon as he is called to them. In by far the majority of cases a few minutes’ delay would be of no consequence ; but as it is impossible to say when the highly urgent cases may occur, the house-surgeon — having due regard to public opinion and the verdict of a coroner’s jury — should always give his immediate attendance. The decision as to the necessity for the admission of a case of accident is sometimes a matter of difficulty, and will be influenced a good deal by the number of vacant beds, &c., but in doubtful cases it is much better to err on the safe side, and take in a patient for a day or two, than to run any risk of mischief occurring during treatment as an out-patient. This is especially advisable in any case brought by the police, and likely to be the subject of legal investigation. Cases present themselves occasionally at hospitals which are obviously unfitted for admission, either from being incurable, or from the fact that they are suffering from want rather than disease. These, if summarily dismissed, may be bandied about between workhouse officials, until (as has positively occurred) the unfortunate sufferer has died of inanition in the street. A coroner’s jury, finding that admission was refused to a patient in a dying condition, will naturally lay the onus upon the house-surgeon, whom it behoves, therefore, to take some little

MINOR SURGERY AND BANDAGING.

pains to avoid such a misfortune by calling the attention of the lay officials to the case, when they will at least give some nourishment to the applicant before he is dismissed, and possibly take steps to secure his immediate admission into a suitable asylum.

A house-surgeon is a good deal pestered for Certificates of illness for clubs, &c., and should he provided with printed form's, which can he readily filled up. Caution should he exercised in giving certificates to the police (except when a patient is unable to appear), since the house-surgeon may lose a fee by not having appeared in person at a police-court.

The following are the principal points of Law affecting the house-surgeon.

The house-surgeon cannot claim any fee for evidence at an inquest upon a patient who died in the hospital, and it is sometimes a nice point to decide whether a death took place outside the hospital doors or not. If the subject of the inquest was brought in dead, the house-surgeon is entitled to one guinea for giving evidence, and one for the post-mortem examination, provided the coroner has given an order for it to be made ; and the house-surgeon should he careful not to give evidence without receiving a summons in due form, and particularly not to make a post-mortem without a written order, or he will forfeit his fees. The house-surgeon must give evidence before a magistrate, if summoned, and there is no fee allowed unless the case he sent for trial, when half-a-guinea will be allowed for each day’s attendance at the police-court, and it is as well to ask the magistrate to enter the attendance at the police-court upon the depositions, so that there may he no mistake after the trial. Although the magistrate has no power to give a fee for evidence on a case which is not sent for trial, the fee of a guinea may he obtained (as I have myself experienced) by writing a formal letter to the Secretary of State for the Home Department, Whitehall, stating the circumstances, when in a few days, probably, an order will he received for payment of the fee. At

INTRODUCTION.

assizes or sessions the house-surgeon is hound to attend on the day he is summoned, and to wait until he is called on, and is allowed a guinea a day for such attendance, and reasonable travelling expenses if he has to go any distance. The fees (including those due for the police-court) are paid as soon as the trial of the case is concluded.

In civil actions the fee will vary according to the ■liberality of the attorney, but will never be less than a guinea a day and travelling expenses ; when served with a subpoena to attend, the house-surgeon should receive current coin of the realm sufficient to defray his travelling expenses, or is not bound to pay any attention to it. When there is doubt of the respectability of the parties, it is well to insist upon having the fee before giving evidence; or if the attorney refuse this, the house-surgeon should appeal to the presiding judge before being sworn, when the judge will direct that the usual fees should be paid : if this is not done, the house-surgeon is at liberty to decline to give evidence. Ey taking this course of appealing to the judge, the author succeeded once in obtaining the fees for giting evidence in an ‘ attorney’s action,’ when a medical friend, who neglected the precaution, failed to obtain any remuneration.*

In order that a house-surgeon may fulfil his duties efficiently, it is essential that he should be careful of his own health. The labour, anxieties, and foul air of an hospital produce an effect upon the strongest constitution in a few weeks, and unless the house-surgeon take proper care of himself he will very soon be disabled. A daily cold bath and a daily walk are the great means for maintaining the health and spirits; the walk, particularly, is essential, and is very apt to be shirked, either from want of energy or from over-anxiety for the welfare of the cases. This over-anxiety is not only injurious to the house-surgeon himself, but is bad for the patients also, since it leads to over-frequent visits to the wards, con-

-*,The house-surgeon may advantageously study the “Abstract Acting the medical profession,” contained m tne Medical Directory,”

MINOR SURGERY AND BANDAGING.

stant change of treatment, and a general state of worry. The house-surgeon should he satisfied with the consciousness of having done his best for his patients, and must be content to leave the result in other hands; and though, no doubt, it is annoying to lose patients in whom a great interest has been taken, it is one of the inevitable drawbacks of medical practice.

A good night’s rest is most important for the house-surgeon, but where he is in sole charge of the hospital its attainment is very precarious. On Saturday nights it is, perhaps, of very little use for a house-surgeon to retire early, since the number of broken heads, &c., is generally large at that time ; but on other nights there can be no object in sitting up to unreasonable hours, and even half an hour’s sleep in bed is better than twice that time in an arm-chair. When the house-surgeon is called up in the night it will he well for him to take the opportunity of visiting one or two of the wards occasionally, to see that the night nurses are on the alert, and to soothe any sleepless patient.